Antisocial Personality Disorder Treatment

According to the DSM-5, antisocial personality disorder (ASPD) is characterized by a pervasive pattern of disregarding or violating others’ rights, which stems from childhood or adolescence. Individuals with this personality disorder might regularly lie, exploit others, break the law, act impulsively, and be aggressive and reckless. They might act irresponsibly, failing to honor professional or financial obligations.

Individuals with ASPD also don’t feel any remorse for their hurtful actions. They might reject their diagnosis or deny their symptoms. They often lack the motivation to improve and are notoriously poor self-observers. They simply do not see themselves as others do.

All of this can complicate psychotherapy, which tends to be the treatment of choice for ASPD. There is no research that supports the use of medications for direct treatment of ASPD. But medications may be used for co-occurring conditions and other issues.

Psychotherapy

As with most personality disorders, individuals with ASPD rarely seek treatment on their own, without being mandated to therapy by a court or a significant other. (Court referrals for assessment and treatment may be the most common referral source.) This makes ASPD difficult to treat because these individuals typically aren’t motivated to change their ways.

If individuals with ASPD do seek treatment on their own, it’s typically for a co-occurring disorder. As many as 90 percent of individuals with ASPD can have another disorder—such as an anxiety disorder, depressive disorder, or substance use disorder. They also might struggle with suicidal thoughts and self-harm.

Research into effective treatments has been scarce, and findings have been mixed. Cognitive behavioral therapy (CBT) might be helpful for individuals with milder forms of ASPD, who have some insight into their behavior, and are motivated to improve (e.g., they don’t want to lose their spouse or their job). CBT addresses the distorted beliefs individuals with ASPD have about themselves and others, along with the behaviors that impair their interpersonal functioning, and interfere with achieving their goals.

A recent treatment showing promise is mentalization-based therapy (MBT), an empirically supported intervention for borderline personality disorder, which combines cognitive, psychodynamic, and relational elements, and is based on attachment theory. This structured, manualized treatment has been adapted for use in individuals with ASPD and conduct disorder (the precursor to ASPD, which occurs in kids and teens). Specifically, MBT addresses a person’s ability to recognize and understand the mental states of themselves and others, including thoughts, feelings, beliefs, and desires. It is this ability that is impaired in ASPD. For instance, people with ASPD have a hard time identifying basic emotions.

A 2016 study that looked at the efficacy of MBT in individuals with both ASPD and borderline personality disorder found that MBT reduced “anger, hostility, paranoia, and the frequency of self-harm and suicidal attempts.” It also improved “negative mood, general psychiatric symptoms, interpersonal problems, and social adjustment.”

UpToDate.com recommends that individuals with ASPD who have co-occurring disorders receive the first-line treatment for that disorder. For instance, CBT might be helpful for treating major depression.

In general, if the person is incarcerated, therapy might focus on creating goals for when they’re released, improving social or family relationships, and learning new coping skills. Therapy also might focus on understanding the connections between the person’s feelings and behaviors, effectively dealing with aggression and impulsive behavior, and understanding the consequences of their actions.

Other modalities of psychotherapy, such as group and family therapy, can be helpful. Often people with this disorder find themselves in a group setting, because they aren’t given any treatment choices. However, this might not be conducive, since in most groups, people with ASPD can remain closed off emotionally and have little reason to share with others. It also doesn’t help that these groups are often made up of people suffering from a wide range of mental illness. Groups that are devoted exclusively to ASPD, though rare, are the best choice. That’s because individuals are given a greater reason to contribute and share with others.

Family therapy can be helpful to increase education and understanding among family members of individuals with ASPD. Families often misunderstand and are confused about the cause of antisocial behavior and the idea that it is a disorder. Family therapy also might help individuals with ASPD realize the impact of their behavior, and improve communication.

Hospitalization

Inpatient care is rarely appropriate or necessary for ASPD. If someone with the disorder is hospitalized, it’s usually because they pose a risk to themselves or others, or they need alcohol or drug detoxification or withdrawal monitoring.

Medications

The U.S. Food and Drug Administration hasn’t approved any medications for antisocial personality disorder, and research hasn’t found any medication to be effective. A doctor might prescribe medication to treat comorbid disorders, such as panic disorder or major depression. However, medications that increase the risk for abuse and addiction—such as benzodiazepines—are not recommended.

Some research has suggested that second-generation antipsychotic medication—such as risperidone or quetiapine—and selective serotonin reuptake inhibitors—such as sertraline or fluoxetine—might reduce aggression and impulsivity in ASPD. Lithium and carbamazepine, an anticonvulsant medication, also might be helpful in reducing these symptoms.

Self-Help Strategies

Again, groups can be especially helpful for people with ASPD, if they’re specifically tailored for the disorder. That’s because individuals feel more at ease discussing their feelings and behaviors in front of their peers in this type of supportive modality.

If substance abuse is an issue, attending meetings for Alcoholics Anonymous (A.A.) or Narcotics Anonymous (N.A.) may be helpful, as well. Because gambling is another problem associated with ASPD, Gamblers Anonymous can serve as a valuable support.

St. Nigel, F., and Dudeck, M. (2019). What Might Work When Nothing Seems to Work: Case Formulation in the Treatment of Antisocial Personality Disorder in a Forensic Mental Health Setting. In U. Kramer (Ed.), Case Formulation for Personality Disorders Tailoring Psychotherapy to the Individual Client. London, UK: Academic Press.

Margarita Tartakovsky, M.S.

Margarita Tartakovsky, M.S. is an Associate Editor and regular contributor at Psych Central. Her Master's degree is in clinical psychology from Texas A&M University. In addition to writing about mental disorders, she blogs regularly about body and self-image issues on her Psych Central blog, Weightless.